Claims Customer Service "Clean" Claim
A claim that is accurate, complete and has not been appealed or contested. A clean claim includes all information necessary to determine payor liability and is not reasonably believed to be fraudulent or subject to a necessary release, consent or assignment.

Coordination of Benefits (COB)
Most group plans contain a condition that when a member is covered by two or more health plans, payment will be divided between them so the combined coverage will pay up to 100% of eligible expenses. Claims are to be sent to the primary carrier first, then to the secondary carrier, along with the explanation of benefits.

Coordination of Care (COC)
Coordination with other healthcare practitioners or systems as a part of responsible treatment.

Co-payment
The portion of the service charges that is paid by a member. Practitioners must collect any co-payments due from MHN enrollees and must accept payment from MHN as payment-in-full for covered services. Practitioners may not balance bill enrollees.

CPT Procedure Code
A code designating the type of service rendered.

Credentialing
The process through which the credentials of practitioners are verified, according to MHN policy, and regulatory and accrediting guidelines, before they become network participants.

D

Deductible
The portion of the service charges that must be paid by a member before any insurance coverage applies.

Date of Service (DOS)
The date that services were administered to a member.

E

Electronic Data Interchange (EDI)
The exchange of information between two systems in an electronic format; for example, data interchange between a practitioner (physician, psychologist, social worker) and a payer (MHN).

Explanation of Benefits (EOB)
The statement mailed to members and providers explaining the processing of a claim.

F

Foundation Health Systems
Former name of MHN parent company.(Foundation Health PsychCare Services and Occupational Health Services are former MHN company names.)

Health Net of Connecticut (HNCT)
The health plan owned and operated by Health Net, Inc., operating in the state of Connecticut.

I

Insured
The primary holder of the insurance (typically the employee), also referred to as the subscriber.

J

Joint Commission on Accreditation of HealthCare Organization (JCAHO)
An independent not-for-profit organization committed to improving the quality of care, through setting standards and providing accreditation to health care organizations that meet those standards.

K

L

Level of Care Criteria/Medical Necessity Guidelines
These are the guidelines used by MHN to determine medical necessity of services requested for coverage and to determine the appropriate level of care for requested treatment.

M

Member Number
The number used by MHN to identify the person accessing services.

Member Service Team
The Centers for Medicare & Medicaid services (CMS)'s, (formerly HCFA) -1500 claims form.

N

NPI
The NPI is a unique identification number for health care providers that will be used by all health plans.

O

P

Patient
The person accessing the service (may be the subscriber or a dependent of the subscriber).

Practitioner Identification Number (PIN)
This is the number assigned to all MHN network practitioners at the time of data entry into our database. Practitioners are advised of this number upon acceptance into the MHN network. The practitioner number is also printed on authorization paperwork.

Professional Relations (PR)
Professional Relations at MHN is concerned with establishing and maintaining our partnership with our network practitioners; this includes recruiting and contracting, credentialing and re-credentialing functions.

Q

R

Re-Credentialing
This is the process through which the credentials of MHN network practitioners are verified, according to MHN policy, and regulatory and accrediting guidelines.

Remittance Advice (RA)
The Remittance Advice (RA) serves as the Explanation of Benefits (EOB) from MHN. The RA is sent when a claim is processed. Network providers may also log in to obtain an Electronic Remittance Advice (ERA). Non-network physicians may request an ERA by completing the Remittance Advice Request form.

Request for Reauthorization (RFR)
The section of the Request for Reauthorization/Closed Case form in CIMS kits that is used to request additional sessions. For further information, please consult the MHN Practitioner Manual, Section 10.2. Clinical Information Management System (CIMS).